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Get Revised 4/27/2011 MSC Individual Withdrawal Verification Form ...

4 - VER MSC Individual Withdrawal Verification Form Section I. Individual Information Name: First Last MI This form is to be used by the DDSO to verify that all individuals requesting to be withdrawn from MSC: * * * * Made this decision on their own without any pressure from another person or an MSC vendor; Understand what it means to be no longer receiving MSC; Are not interested in pursuing other vendor/provider options; Understand that if they are in the HCBS Waiver, they will be re.

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